TITLE 8 SOCIAL SERVICES
CHAPTER 314 LONG TERM CARE SERVICES - WAIVERS
PART 7 SUPPORTS WAIVER
8.314.7.1 ISSUING AGENCY: New
Mexico Human Services Department (HSD).
[8.314.7.1 NMAC - N, 4/1/2021]
8.314.7.2 SCOPE: The
rule applies to the general public.
[8.314.7.2 NMAC - N,
4/1/2021]
8.314.7.3 STATUTORY AUTHORITY: The
New Mexico medicaid program and other health care
programs are administered pursuant to regulations promulgated by the federal
department of health and human services under Titles XI, XIX, and XXI of the
Social Security Act as amended or by state statute. See Section 27-2-12 et seq. NMSA 1978.
[8.314.7.3 NMAC - N,
4/1/2021]
8.314.7.4 DURATION:
Permanent.
[8.314.7.4 NMAC - N,
4/1/2021]
8.314.7.5 EFFECTIVE DATE: April 1, 2021, unless a later date is cited
at the end of a section.
[8.314.7.5 NMAC - N,
4/1/2021]
8.314.7.6 OBJECTIVE: The
objective of this rule is to provide instructions for the service portion of
the New Mexico medical assistance programs (MAP).
[8.314.7.6 NMAC - N,
4/1/2021]
8.314.7.7 DEFINITIONS:
A. Activities of
daily living (ADLs): Basic personal
everyday activities that include bathing, dressing, transferring (e.g., from
bed to chair), toileting, mobility and eating.
B. Adult: An individual who is 18 years of age or
older.
C. Agency-based: Supports waiver service
delivery model offered to an eligible recipient who does not want to direct
their supports waiver services.
Agency-based services are provided by an agency with an approved
agreement with department of health (DOH) to provide supports waiver services.
D. Authorized
annual budget (AAB): The total
approved annual amount of the community support services and goods which
includes the frequency, the amount, and the duration of the waiver services and
the cost of waiver goods approved by the third-party assessor (TPA).
E. Authorized
representative: The individual
designated to represent and act on the recipient’s behalf. The authorized representative does not have
budget or employer authority. The
eligible recipient or authorized representative must provide legal
documentation authorizing the named individual or individuals for a specified purpose and time
frame. An authorized representative may
be an attorney representing a person or household, a person acting under the
authority of a valid power of attorney, a guardian, or other legal
designation. The eligible recipient’s
authorized representative may not be a service provider. The authorized representative may not approve
their own timesheets. The authorized
representative cannot serve as the eligible recipient’s community supports
coordinator.
F. Category of eligibility (COE): To qualify for a medical
assistance program (MAP), an applicant must meet financial criteria and belong
to one of the groups that the New Mexico medical assistance division (MAD) has
defined as eligible. An eligible
recipient in the supports waiver program must belong to the MAP categories of
eligibility (COE) described in 8.314.7.9 NMAC.
G. Centers for medicare and medicaid services (CMS): Federal agency within the United States
department of health and human services that works in partnership with New
Mexico to administer medicaid and MAP services under
HSD.
H. Child: An
individual under the age of 18. For
purpose of early periodic screening, diagnosis, and treatment (EPSDT) services
eligibility “child” is defined as an individual under the age of 21.
I. Community supports coordinator (CSC): An agency or an individual that provides case
management services to the eligible recipient that assist the eligible
recipient in arranging for, directing and managing supports waiver program
services and supports, as well as developing, implementing and monitoring the
individual service plan (ISP) and AAB.
J. Electronic visit verification
(EVV): A telephone and computer-based system
that electronically verifies the occurrence of HSD selected service visits and
documents the precise time the service begins and ends.
K. Eligible recipient: An
applicant meeting the financial and medical level of care (LOC) criteria who is
approved to receive MAD services through the supports waiver.
L. Employer of record
(EOR): The employer of record (EOR) is the individual responsible for directing
the work of the support’s waiver employees, including recruiting, hiring,
managing and terminating employees. The
EOR is responsible for directing the work of any vendors contracted to perform
services. The EOR tracks expenditures
for employee payroll, goods, and services.
EORs authorize the payment of timesheets and vendor payment requests by
the financial management agency (FMA).
An eligible recipient may be their own EOR unless the eligible recipient
is a minor or has a plenary or limited guardianship or conservatorship over
financial matters in place. An EOR must
be the waiver participant or an EOR must be a legal representative of the
recipient.
M. Financial management agency (FMA): HSD
contractor that helps implement the AAB by paying the eligible recipient’s
service providers and tracking expenses.
N. Individual budgetary allotment (IBA): The
maximum budget allotment available to an eligible recipient. The maximum IBA under the supports waiver is
$10,000 dollars. Based on this maximum
amount, the eligible recipient will develop a plan to meet his or her assessed
functional, medical, and habilitative needs to enable
the recipient to remain in the community.
O. Individual
service plan (ISP): The ISP is the name of the person-centered plan for
the supports waiver. The ISP
includes waiver services that meet the eligible recipient’s needs including: the projected amount,
the frequency and the duration
of the waiver services; the type of provider who will furnish each waiver service;
other services the eligible recipient will access; and the eligible recipient’s available supports
that will complement waiver services in meeting their needs.
P. Intermediate care facilities for individuals
with intellectual disabilities (ICF/IID):
Facilities that are
licensed and certified by the New Mexico department of health to provide room
and board, continuous active treatment
and other services
for eligible MAD recipients with a primary
diagnosis of intellectually disabled.
Q. Legal representative:
A person that is a legal guardian, conservator, power of attorney or
otherwise has a court established legal relationship with the eligible
recipient. The eligible recipient must
provide certified documentation to the community support coordinator provider
and FMA of the legal status of the representative and such documentation will become part of the eligible
recipient’s file.
R. Level of care (LOC): The level of care an eligible recipient must meet to be eligible for the supports waiver program.
S. Participant directed: Supports waiver service delivery model
wherein the eligible recipient identifies, accesses and manages the employees
and vendors of services (among the state-determined waiver services and goods)
that meet their assessed therapeutic,
rehabilitative, habilitative, health or safety needs
to support the eligible recipient to remain
in their community.
T. Person-centered planning (PCP): Person-centered planning is a process that places a person at the center of planning their life and supports. It is an ongoing process that is the foundation for all aspects of the supports waiver and provider’s work with individuals with intellectual/developmental disabilities (I/DD). The process is designed to identify the strengths, capacities, preferences, needs, and desired outcomes of the eligible recipient. The process may include other persons, freely chosen by the eligible recipient who are able to serve as important contributors to the process. It involves person-centered thinking, person-centered service planning and person-centered practice. The PCP enables and assists the recipients’ strengths, capacities, preferences, needs, and desired outcomes of the eligible recipient.
U. Reconsideration: A
written request by an eligible recipient who disagrees with a clinical/medical
utilization review decision or action submitted to the third-party assessor for
reconsideration of the decision. The
eligible recipient or his or her authorized representative may submit the
request for a reconsideration through the community
support coordinator or the community support coordinator agency may submit the
request directly to MAD.
V. Third-party assessor (TPA): The MAD contractor who determines and
re-determines LOC and medical eligibility for the supports waiver program. The TPA also reviews the eligible recipient’s
ISP and approves the AAB for the eligible recipient. The TPA performs utilization management
duties for all supports waiver services.
W. Waiver: A
program in which the federal government has waived certain statutory
requirements of the Social Security Act to allow states to provide an array of
home and community-based service options through MAD as an alternative to
providing long-term care services in an institutional setting.
[8.314.7 NMAC - N, 4/1/2021]
8.314.7.8 MISSION STATEMENT: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human services that improve the
security and promote independence for New Mexicans in their communities.
[8.314.7.8 NMAC - N, 4/1/2021]
8.314.7.9 SUPPORTS
WAIVER HOME AND COMMUNITY-BASED SERVICES:
A. New
Mexico’s supports waiver is designed to provide temporary assistance to those
on the developmental disabilities (DD) waiver wait list. It is intended to provide support services to
eligible recipients to enable work toward self-determination, independence,
productivity, integration, and inclusion in all facets of community life across
the lifespan. The services provided are
intended to build on each eligible recipient’s current support structures
through person-centered planning to work toward individually defined life
outcomes, focusing on developing the eligible recipient’s abilities for self-determination,
community living and participation, and economic self-sufficiency. An eligible recipient has a choice of
receiving services through the agency-based service delivery model or the
participant directed service delivery model.
B. The
program is operated by the New Mexico department of health developmental
disabilities supports division (DOH/DDSD), at the direction of the New Mexico
human services department medical assistance division (HSD/MAD).
[8.314.7.9 NMAC - N,
4/1/2021]
8.314.7.10 ELIGIBLITY REQUIREMENTS FOR
RECIPIENT ENROLLMENT: Enrollment in the supports waiver is
contingent upon the applicant meeting the eligibility requirements, the
availability of funding as appropriated by the New Mexico legislature, and the
number of federally authorized unduplicated eligible recipients. When sufficient funding is available, DOH
will offer the supports waiver to eligible recipients on the DD wait list. Once an
offer has been given to the applicant, they must meet certain medical and
financial criteria in order to qualify for enrollment. Eligible recipients must meet the following
eligibility criteria: financial eligibility criteria determined in accordance with 8.290.400 NMAC;
the eligible recipient
must meet the
level of care (LOC) required for admittance to an intermediate care
facility for individuals with intellectual disabilities (ICF/IID); and
additional specific criteria as specified in the categories below.
[8.314.7.10 NMAC -
N, 4/1/2021]
8.314.7.11 ELIGIBLE
RECIPIENT RESPONSIBILITIES: Supports
waiver eligible recipients have responsibilities to participate in the
program. Failure to comply with these
responsibilities or other program rules and service standards can result in
termination from the program. The
eligible recipient has the following responsibilities:
A. To maintain eligibility the recipient must complete
required documentation demonstrating medical and financial eligibility both
upon application and annually at recertification, and seek assistance with the
application and the recertification process as needed from a community supports
coordinator (CSC).
B. To participate in the supports waiver program, the
eligible recipient must:
(1) comply with applicable NMAC rules to
include this rule and supports waiver service standards and requirements that
govern the program;
(2) collaborate with the CSC to choose
between the agency-based or participant directed service delivery models, and
determine support needs related to planning and self direction as applicable;
(3) collaborate with the CSC to develop
an ISP and budget using the IBA in accordance with applicable NMAC rules to
include this rule and supports waiver service standards;
(4) use supports waiver program funds
appropriately by only requesting and purchasing goods and services covered by
the supports waiver program in accordance with program rules which are
identified in the eligible recipient’s approved ISP and budget;
(5) comply
with the approved ISP and not exceed the AAB;
(a) if the eligible recipient, due to
mismanangement or failure to properly track expenditures, prematurely depletes
the AAB amount during an ISP year, the failure to properly manage the AAB does
not substantiate a claim for a budget increase (e.g. if all of the AAB is
expended within the first three months of the ISP year, it is not justification
for an increase in the budget for the ISP year);
(b) revisions to the AAB may occur
within the ISP year, and the eligible recipient is responsible for ensuring that
all expenditures are in compliance with the most current AAB in effect;
(i) the ISP must be amended to reflect a change in the
eligible recipient’s needs or circumstances before any revisions to the AAB can
be requested;
(ii) other than for critical health and
safety reasons, budget revisions may not be submitted to the TPA for review
within the last 60 calendar days of the budget year;
(c) no supports waiver program funds
can be used to purchase goods or services prior to TPA approval of the ISP and
annual budget request;
(d) any funds not utilized within the
ISP and AAB year cannot be carried over into the following year;
(6) access CSC services based upon identified need(s) in
order to carry out the approved ISP;
(7) collaborate with the CSC to appropriately document
service delivery and maintain documents for evidence of services received;
(8) report concerns or problems with any part of the
supports waiver program to the community supports coordinator or if the concern
or problem is with the CSC, to DOH;
(9) work with the TPA by
providing documentation and information as requested;
(10) respond to requests for additional documentation and
information from the CSC provider, FMA, and the TPA within the required
deadlines;
(11) report to the local HSD income support division (ISD)
office within 10 calendar days any change in circumstances, including a change
in address, which might affect eligibility for the program; changes in address
or other contact information must also be reported to the CSC provider and the
financial management agency (FMA) within 10 calendar days;
(12) report to the TPA and CSC provider if hospitalized for more
than three consecutive nights so that an appropriate LOC can be obtained;
(13) have monthly contact and meet face-to-face quarterly
with the CSC, as required by the DOH; and
(14) comply with all electronic visit verification (EVV)
requirements.
C. Specific
responsbilities for eligible recipient in participant directed service delivery
model: In addition to the requirements in Subsection A and B of 8.314.7.11
NMAC, the eligible recipient must have an employer of record (EOR) to
participate in the participant directed service delivery model. The EOR may be the eligible recipient unless
the eligible recipient is a minor or has a plenary or limited guardianship or
conservatorship over financial matters in place. An EOR must be the waiver participant or an
EOR must be a legal representative of the recipient. The eligible recipient as their own EOR or
the designated EOR must:
(1) direct the
work of supports waiver employees, including recruiting, hiring, managing and
terminating all employees;
(2) direct the
work of any vendors contracted to perform services;
(3) track expenditures for employee
payroll, goods, and services;
(4) authorize the payment of timesheets
and vendor payment requests by the FMA;
(5) keep
track of all budget expenditures and ensure that all expenditures are within
the AAB;
(6) submit all required documents to the FMA to meet
employer-related responsibilities. This
includes, but is not limited to, documents for payment to employees and vendors
and payment of taxes and other financial obligations within required timelines;
(7) complete all trainings
within the required timeframes by the DOH or medical assistance division (MAD);
(8) ensure that all
employees have registered and completed required trainings within the
timeframes required by the DOH or MAD,
identified in the ISP or identified by the EOR;
(9) report any incidents of abuse,
neglect or exploitation to the appropriate state agency;
(10) arrange for the delivery of services,
supports and goods;
(11) maintain records and documentation for at least six
years from first date of service and ongoing; and
(12) comply with all electronic visit verification (EVV)
requirements.
D. Voluntary
termination: The supports waiver
eligibile recipient may voluntarily terminate services through the supports
waiver and will not lose their place on DD waiver wait list.
E. Involuntary termination: A supports waiver eligible recipient may be
terminated involuntarily by MAD and DOH for the following:
(1) the eligible recipient refuses to comply with 8.314.7
NMAC and the supports waiver service standards, after receiving focused
technical assistance from DOH and MAD program staff, CSC, or FMA, which is
supported by documentation of the efforts to assist the eligible recipient;
(2) the eligible recipient is an immediate risk to their health
or safety, imminent risk of death or serious bodily injury, by continued
participant direction of services.
Examples include but are not limited to the following:
(a) the eligible recipient refuses to
include and maintain services in their ISP and AAB that would address health
and safety issues identified in their ISP or challenges the ISP after repeated and focused technical assistance and
support from program staff, CSC, or FMA;
(b) the eligible recipient is
experiencing significant health or safety needs, and either refuses to incorporate a plan to address
health and safety needs or document applicable choices in ISP;
(c) the eligible recipient exhibits
behaviors which endanger themselves or others after repeated and focused
technical assistance and support from program staff, CSC, or FMA.
(3) the eligible recipient misuses
suppports waiver funds following repeated and focused technical assistance and
support from the CSC or FMA, which is supported by documentation;
(4) the eligible recipient commits
medicaid fraud;
(5) when the DOH is notified that the
eligible recipient continues to utilize either an employee or a vendor, or
both, who have consistently been substantiated against for abuse, neglect or
exploitation while providing supports waiver services after notification of
this by DOH;
[8.314.7.11 NMAC -
N, 4/1/2021]
8.314.7.12 SUPPORTS WAIVER CONTRACTED
ENTITIES AND PROVIDERS: Services are to be provided in the least
restrictive manner. The HSD does not
allow for the use of any restraints, restrictive interventions, or seclusions
to an eligible supports waiver recipient.
The following resources and services have been established to assist
eligible recipients to access supports waiver services through the agency-based
service delivery model or the participant directed service delivery model. These include the following:
A. Community supports coordinator (CSC) services: CSC services are direct services intended to
assist the eligible recipient in attaining and maintaining medical and
financial eligibility; educating, guiding and assisting the eligible recipient
to make informed planning decisions about service and supports; developing an
ISP through a person-centered planning process; implementing and monitoring the
ISP and AAB; and under the agency-based service delivery model, arranging for,
directing, and managing supports waiver services and supports.
B. Financial management agency (FMA): For eligible recipients selecting the
participant directed service delivery model, the FMA acts as the intermediary
between the eligible recipient and the MAD payment system and assists the
eligible recipient or the EOR with employer-related responsibilities. The FMA pays employees and vendors based upon
an approved AAB. The FMA assures there is eligible recipient and program compliance with state and federal
employment requirements and monitors and makes available to the eligible
recipient the reports related to utilization of services and budget
expenditures. Based on the eligible
recipient’s approved ISP and AAB, the FMA must:
(1) verify that the recipient is eligible for MAD services prior
to making payment;
(2) receive and
verify all required employee and vendor documentation;
(3) establish an accounting for each
eligible recipient’s AAB;
(4) process and
pay invoices for goods, services and supports approved in the ISP and the AAB
and supported by required documentation;
(5) process all
payroll functions on behalf of the eligible recipient and EORs including:
(a) collect and
process timesheets of employees;
(b) process payroll, withholding, filing, and payment of
applicable federal, state and local employment-related taxes and insurance; and
(c) track and report disbursements and
balances of the eligible recipient’s AAB and provide a monthly report of
expenditures and budget status to the eligible recipient and their CSC, and
quarterly and annual documentation of expenditures to the MAD;
(6) receive and
verify employee and vendor agreements, including collecting required provider
qualifications;
(7) monitor hours, the total amounts
billed for all goods and services during the month;
(8) process and
report on employee background checks;
(9) answer
inquiries from the eligible recipient and solve problems related to the FMA
responsibilities; and
(10) report to the
CSC provider, MAD and DOH any concerns related to the health and safety of an
eligible recipient, or if the eligible recipient is not following the approved
ISP and AAB.
C. Third-party assessor (TPA): The
TPA or MAD’s designee is responsible for determining medical eligibility
through a LOC assessment, approving the ISP, and authorizing an eligible
recipient’s annual budget in accordance with 8.314.7 NMAC and the supports
waiver service standards. The TPA:
(1) determines medical eligibility using
the LOC criteria in 8.314.7.9 NMAC; determinations are completed initially for
an eligible recipient who is newly enrolled in the supports waiver and
thereafter at least annually for currently enrolled supports waiver eligible
recipients. The TPA may re-evaluate LOC
more often than annually if there is an indication that the eligible
recipient’s medical condition or LOC has changed; and
(2) approves the
ISP and the annual budget request resulting in an AAB, at least annually or
more often if there is a change in the eligible recipient’s circumstances, in
accordance with this NMAC and supports waiver service standards.
D. Conflict of interest: An eligible recipient’s CSC
may not serve as the eligible recipient’s EOR, authorized representative or
personal representative for whom they are the CSC. A CSC may not be paid for any other services
utilized by the eligible recipient for whom they are the CSC, whether as an
employee of the eligible recipient, a vendor, an employee or subcontractor of
an agency. A CSC may not provide any
other paid supports waiver services to an eligible recipient unless the
recipient is receiving CSC services from another agency. The CSC agency may not provide any other
direct services for an eligible recipient that has an approved ISP, an approved
budget, and is actively receiving services in the supports waiver program. The CSC agency may not employ as a CSC any
immediate family member or guardian for an eligible recipient of the supports
waiver program that is served by the CSC agency. A CSC agency may not provide guardianship
services to an eligible recipient receiving CSC services from that same
agency. The CSC agency may not provide
any direct support services through any other type of 1915 (c) developmental
disabilities waiver program. A CSC
agency shall not engage in any activities in their capacity as a provider of
services to an eligible recipient that may be a conflict of interest. As such a CSC agency shall not hold a
business or financial interest in an affiliated agency that is paid to provide
direct care for any eligible recipients receiving supports waiver
services. An affiliated agency is
defined as a direct service agency providing supports waiver services that has
a marital, domestic partner, blood, business interest or holds financial
interest in providing direct care for eligible recipients receiving supports
waiver services. Affiliated agencies
must not hold a business or financial interest in any entity that is paid to
provide direct care for any eligible recipients receiving home and
community-based services (HCBS). Any
direct service agency or CSC agency that has been referred to the DOH internal
review committee (IRC) or is on a moratorium will not be approved to provide supports
waiver services.
[8.314.7.12 NMAC -
N, 4/1/2021]
8.314.7.13 QUALIFICATIONS FOR ELIGIBLE
INDIVIDUAL EMPLOYEES, INDEPENDENT PROVIDERS, PROVIDER AGENCIES, AND VENDORS:
A. Agency-based service delivery
model requirements for individual employees, independent providers,
provider agencies and vendors: All
supports waiver eligible providers under the agency-based model of
service delivery must be approved
by the DOH or its designee and have an approved
MAD and DOH provider agreement. MAD through its designee, DOH/DDSD, must ensure that its subcontractors or employees meet
all required qualifications. The
provider agency must provide oversight of subcontractors and supervision of
employees to ensure that all required MAD and DOH/DDSD qualifications;
compliance with EVV requirements; all requirements outlined in the supports waiver services standards, applicable New
Mexico administrative code (NMAC) rules, MAD supplements, and as applicable, the provider’s New Mexico licensing board’s scope of practice
and licensure are met.
B. Participant directed service
delivery model requirements for
individual employees, independent providers, and vendors: In order to be approved to provide
services under the participant directed service delivery model, provider
agency, employees, vendors, or an independent provider, including non-licensed
personal care or direct support worker, must meet the general and service
specific qualifications set forth in this rule initially and continually meet
licensure requirements as applicable, and submit an employee or vendor
enrollment packet, specific to the provider or vendor type, for approval to the
FMA. In addition, to be an authorized
provider for the supports waiver and receive payment for delivered services,
the provider must complete a vendor or employee provider agreement and all
required tax documents. The provider
must have credentials verified by the eligible recipient or the employee of
record (EOR) and the FMA. The provider
agency is responsible to ensure that all agency employees meet the required
qualifications. Individual employees may
not provide more than 40 hours of services in a consecutive seven-day work
week.
(1) prior to rendering services to an
eligible supports waiver recipient as a personal care or direct support worker,
respite worker, customized community supports worker, or employment worker, an
individual seeking to provide these services must complete and submit a nature
of services questionnaire to the FMA.
The FMA will determine, based on the nature of services questionnaire if
the relationship is that of an employee or an independent contractor;
(2) an
authorized CSC provider must have a MAD approved provider participation
agreement (PPA) and the appropriate approved DOH/DDSD agreement.
C. General Qualifications agency-based and participant
directed service delivery model providers:
(1) individual
employees, independent providers, provider agencies, excluding CSC provider
agencies, who are employed by a community supports waiver recipient to provide
direct services shall:
(a) be at least
18 years of age;
(b) be qualified
to perform the service and demonstrate capacity to perform required tasks;
(c) be able to
communicate successfully with the eligible recipient;
(d) pass a nationwide caregiver criminal
history screening pursuant to NMSA 1978, Section 29-17-2 et seq. and 7.1.9 NMAC
and an abuse registry screen pursuant to NMSA 1978, Section 27-7a-1 et seq. and
8.11.6 NMAC;
(e) complete all
trainings as required by DOH/DDSD and complete training specific to the
eligible recipient’s needs as identified in the approved ISP;
(f) for participant directed, training
needs on items identified in the individual service plan (ISP), and the
training plan is determined by the eligible recipient or their legal
representative for any training specific to the employee in addition to
trainings required by DOH/DDSD; the eligible recipient is also responsible for
providing and arranging for employee training and supervising employee
performance; training expenses for paid employees cannot be paid for with the
eligible recipient’s AAB; and
(g) meet any
other service specific qualifications, as specified in 8.314.7 NMAC and service
standards.
(2) vendors,
including those providing professional services:
(a) shall be
qualified to provide the service;
(b) shall
possess a valid business license, if applicable;
and
(c) are required
to follow the applicable licensing regulations set forth by the profession; refer to the appropriate New Mexico board of licensure for information regarding
applicable licenses;
(3) qualified and approved relatives and legal guardians may be hired as employees and paid for the provision, of supports waiver services except for CSC services, customized community supports group services, non-medical transportation services for a minor, environmental modifications services, vehicle modifications services, behavior support consultation services, assistive technology and employment supports. A spouse may not provide transportation for adult participants. A relative or legal guardian may not provide services that the legal responsible individual would ordinarily perform in the household for individuals of the same age who did not have a disability or chronic illness. A relative or legal guardian may not provide services that the legally responsible individual would ordinarily perform in the household for individuals of the same age who did not have a disability or chronic illness;
(4) once enrolled,
providers, vendors and contractors receive a packet of information from the
eligible recipient or FMA including billing instructions, and other pertinent
materials. MAD makes available on the
HSD/MAD website, on other program-specific websites, or in hard copy format,
information necessary to participate in health care programs administered by
HSD or its authorized agents, including program rules, billing instructions,
utilization review instructions, and other pertinent materials. When enrolled, an eligible recipient or legal
representative, or provider, vendor or contractor receives instruction on how to access these
documents. It
is the responsibility of the eligible recipient or legal representative, or provider, vendor, or
contractor to access these instructions or ask for paper copies to be provided,
to understand the information provided and to comply with the
requirements. The eligible recipient or
legal representative, or provider, vendor, or contractor must contact HSD or
its authorized agents to request hard copies of any program rules manuals,
billing and utilization review instructions, and other pertinent materials and
to obtain answers to questions on or not covered by these materials;
(a) no provider
of any type may be paid in excess of 40 hours within the established work week for any one eligible recipient
or EOR when applicable;
(b) no
provider agency is permitted to perform both LOC assessments and provide any services for the eligible
recipients;
(c) providers may market their services
but are prohibited from soliciting eligible recipients
under any circumstances.
(5) Employer of record: The EOR is the individual responsible for directing the work of the eligible
recipient’s employees under
the participant directed service delivery model. The EOR may be the eligible recipient or a
legal representative of the recipient. A
recipient through the use of the support’s waiver EOR questionnaire will
determine if an individual meets the requirements to serve as an EOR. The recipient’s CSC will provide him or her
with the questionnaire. The
questionnaire shall be completed by the recipient with assistance from the CSC
upon request. The CSC shall maintain a
copy of the completed questionnaire in the recipient’s file. The EOR does not have budget authority. When utilizing both vendors and employees, an
EOR is required for oversight of employees and to sign payment request forms
for vendors. The EOR must be documented
with the FMA whether the EOR is the eligible recipient or a designated
qualified individual.
(a) an eligible
recipient that is the subject of a plenary or limited guardianship or conservatorship may not be their own EOR;
(b) a power of attorney or other legal
instrument may not be used to assign EOR responsibilities, in part or in full,
to another individual and may not be used to circumvent the requirements of the
EOR as designated in 8.316.7 NMAC;
(c) a person
under the age of 18 years may not be an EOR;
(d) an EOR
who lives outside New Mexico shall reside within 100 miles of the New Mexico
state border. If the eligible recipient wants to have an
EOR who resides beyond this radius, the eligible recipient must obtain written
approval from the DOH prior to the EOR performing any duties. This written approval must be documented in
the ISP;
(e) the eligible
recipient’s provider may not also be their EOR;
(f) an EOR whose performance compromises the health,
safety or welfare
of the eligible recipient, may have their status as an EOR terminated;
(g) an EOR
must be a legal representative if not the recipient; and
(h) an EOR
may not be paid for any other services utilized by the eligible recipient for
whom they are EOR, whether as an employee of the eligible recipient, a vendor,
or an employee or contractor of an agency.
An EOR makes important determinations about what is in the best interest
of the eligible recipient and should not have any conflict of interest. An EOR assists in the management of the
eligible recipient’s budget and should have no personal benefit connected to
the services requested or approved in the budget.
D. Qualifications of assistive
technology providers and vendors: Must hold a current business
license issued by the state, county or city government.
E. Qualifications
of behavior support consultation providers:
Behavior supports
consultation provider agencies shall have a current business license issued by
the state, county or city government, if required. Behavior supports consultation provider
agencies shall comply with all applicable federal, state, and waiver rules and
procedures regarding behavior support consultation, and must ensure that
provider training is in accordance with the DOH/DDSD training policy. Providers of behavior support consultation must
maintain a current New Mexico license with the appropriate professional field
licensing body and have a minimum of
one year of experience working with individuals with intellectual or
developmental disabilities. Providers of
behavior support consultation services must possess qualifications in at least
one of the following areas:
(1) licensed clinical psychologist, licensed psychologist associate, (masters or
Ph.D. level);
(2) licensed independent social worker (LISW) or a licensed clinical social worker
(LCSW);
(3) licensed master social worker (LMSW);
(4) licensed mental health counselor LMHC);
(5) licensed professional clinical counselor (LPCC);
(6) licensed marriage and family therapist (LMFT); or
(7) licensed practicing art therapist (LPAT).
F. Qualifications of the community
support coordinator providers: In addition to general requirements, a CSC provider
shall ensure that all individuals hired, or contracted for CSC services meet the
criteria specified in this section in addition to all applicable rules and
service standards. Community supports coordinators shall:
(1) be at least
21 years of age;
(2) possess a bachelor’s degree in social
work, psychology, human services, counseling, nursing, special education or
related field; or have a minimum of six-years direct experience related to the
delivery of social services to people with disabilities;
(3) have at least one year of experience
working with people with disabilities or I/DD;
(4) complete all trainings as
required by DOH/DDSD;
(5) verification
of provider qualifications; and
(6) pass a
national care giver criminal history screening pursuant to Section 29-17-2 et
seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27a-4 et seq. NMSA 1978 and 8.11.6 NMAC.
G. Qualifications for customized community supports individual providers: For individual community
supports providers the worker must meet the following requirements:
(1) be 18 years
of age or older;
(2) demonstrate the capacity to perform
required tasks;
(3) be able
to communicate successfully with the eligible recipient;
(4) complete
all training requirements as required by DOH/DDSD; and
(5) pass
a national care giver criminal history screening pursuant to Section 29-17-2 et
seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27a-4 et seq. NMSA 1978 and 8.11.6 NMAC; and
(6) meet any
other service qualifications, as specified in the regulations.
H. Qualifications for customized
community supports group providers: Provider agencies must meet requirements
including a business license, accreditation with the commission on
accreditation of rehabilitation facilities (CARF) international, employment and
community services or the council on quality and leadership, quality
assurances, financial solvency, training requirements, records management,
quality assurance policy and processes.
The agency staff must meet the following requirements:
(1) be at
least 18 years of age;
(2) have at least one year of
experience working with people with disabilities;
(3) be
qualified to perform the service and demonstrate capacity to perform required
tasks;
(4) be able
to communicate successfully with the eligible recipient;
(5) pass a national care giver criminal history
screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an
abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and 8.11.6
NMAC.
(6) complete
specific training based on needs identified in the ISP and by the recipient;
and
(7) meet any
other service qualifications, as specified in the regulations.
I. Qualifications of personal care service providers: In addition to general MAD requirements, the
direct support providers must meet additional qualifications specific to the
type of services provided. Provider
agencies must be homemaker/personal care agencies certified by the MAD or its
designee or a homemaker/personal care agency holding a New Mexico
homemaker/personal care agency license.
A homemaker/personal care agency must hold a current business license
when applicable, and meet financial solvency, training, records management, and
quality assurance rules and requirements.
Personal care direct support workers must:
(1) be at least
18 years of age;
(2) demonstrate capacity to perform
required tasks;
(3) be able
to communicate successfully with the eligible recipient;
(4) complete
all trainings as required by DOH/DDSD; and
(5) pass a
national care giver criminal history screening pursuant to Section 29-17-2 et
seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27a-4 et seq. NMSA 1978 and 8.11.6 NMAC.
J. Qualifications of employment supports providers:
(1) A job
developer, whether an agency or individual provider, must:
(a) be at least
21 years of age;
(b) complete all
training requirements by DOH/DDSD;
(c) have a high
school diploma or GED;
(d) pass a national care giver criminal
history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC
and an abuse registry screen pursuant to Section 27a-4 et seq. NMSA 1978 and
8.11.6 NMAC;
(e) have
experience in developing and using job and task analysis;
(f) have
knowledge of the Americans with Disabilities Act (ADA);
(g) have
knowledge and experience working with the department of vocational
rehabilitation (DVR) office; and
(h) have experience with or knowledge of
the purposes, functions, and general practices of entities such as department
of labor navigators one-stop career centers, business leadership network,
chamber of commerce job accommodation network, small business development
centers, retired executives, local business community agencies, and DDSD
resources.
(2) Job coaches whether agency or
individual provider, must:
(a) be at
least 18 years of age;
(b) complete all training requirements by DOH/DDSD;
(c) have a high
school diploma or GED; and
(d) pass a
national care giver criminal history screening pursuant to Section 29-17-2 et
seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section
27a-4 et seq. NMSA 1978 and 8.11.6 NMAC.
K. Qualifications of environmental modifications
providers: Environmental modification providers must
possess an appropriate plumbing, electrician, contractor license; appropriate
technical certification to perform the modification; and, hold a current
business license issued by the state, county or city government.
L. Qualifications of non-medical
transportation providers: Individual transportation providers
must possess a valid New Mexico driver’s license with the appropriate classification, be free of physical or mental impairment that would adversely affect
driving performance, have no driving
while intoxicated (DWI) convictions or chargeable (at fault) accidents within the previous
two years, have a current insurance policy and vehicle registration. Transportation vendors must hold a current
business license and tax identification number.
Each agency will ensure drivers meet the following qualifications:
(1) be at least
18 years old;
(2) possess
a valid, appropriate New Mexico driver’s license;
(3) have a
current insurance policy and vehicle registration; and
(4) must
complete all training requirements as required by DOH/DDSD.
M. Qualifications of respite providers: Respite services may be provided by eligible
individual respite providers. Respite
provider agencies must hold a current business license, and meet financial
solvency, training, records management and quality assurance rules and requirements. In addition, for participant-directed
services, the eligible recipient or their representative evaluates training
needs based on the needs identified in the ISP and by the recipient, provides
or arranges for training, as needed, and supervises the worker. Respite worker must:
(1) be 18 years of age or older;
(2) demonstrate capacity to perform
required tasks;
(3) be able
to communicate successfully with the eligible recipient;
(4) pass a nationwide caregiver
criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and
7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et seq.
NMSA 1978 and 8.11.6 NMAC; and
(5) complete
all training requirements as required by DOH/DDSD.
N. Qualifications of vehicle modification
providers: Vehicle modification providers must possess
an appropriate mechanic or body work license; appropriate technical
certification to perform the modification; and, hold a current business license
issued by the state, county or city government.
[8.314.7.13 NMAC - N, 4/1/2021]
8.314.7.14 SERVICE
DESCRIPTIONS AND COVERAGE CRITERIA: The services covered by the supports waiver
are intended to provide a community-based alternative to
institutional care for an eligible recipient that allow greater choice, direction and control over services and
supports in an agency-based service delivery model or participant directed
service delivery model.
These services must specifically address a therapeutic, rehabilitative, habilitative, health or safety need that results from the
eligible recipient’s qualifying condition. The supports waiver is the payor of last resort.
The coverage of the services must be in accordance with the supports
waiver rules and service standards.
Supports waiver services must be provided in an integrated setting and
facilitate full access to the community; ensure the eligible recipient receives
services in the community to the same degree of access as those individuals not
receiving HCBS services; maximize independence in making life choices; be
chosen by the eligible recipient in consultation with the guardian as
applicable; ensure the right to privacy, dignity, respect, and freedom from
coercion and restraint; optimize recipient employment; and facilitate choice of
services and who provides them.
A. General
requirements regarding supports waiver covered services: To be considered a covered service under the
supports waiver, the following criteria must be met. Services, supports and goods must:
(1) directly
address the eligible recipient’s qualifying condition or disability;
(2) meet the eligible recipient’s
clinical, functional, medical or habilitative needs;
(3) be designed
and delivered to advance the desired outcomes in the eligible recipient’s
service and support plan; and
(4) support the
eligible recipient to remain in the community and reduce the risk of institutionalization.
B. Assistive technology: Assistive technology (AT) is an item, piece of equipment, or product system used to increase, maintain, or improve functional capabilities. AT services allow for the evaluation and purchase of the AT based on the needs of the eligible recipient and, not covered through the eligible recipient’s state plan benefits. Evaluation of the assistive technology needs of the participant include a functional evaluation of the impact of the provision of the appropriate assistive technology to the participant. Services consist of selecting, designing, fitting, customization, adapting, applying, maintaining, and repair or repairing assistive technology devices. AT services also include training or technical assistance for the participant, or where appropriate, the family members, guardians, advocates, or authorized representatives of the participant, or professionals or direct service providers involved in the major life functions of the participant. AT includes remote personal support technology. Remote personal support technology is an electronic device or monitoring system that supports eligible recipients to be independent in their home or community. This service may provide up to 24-hour alert, monitoring or personal emergency response capability, prompting or in-home reminders, or monitoring for environmental controls for independence through the use of technologies. Remote monitoring is prohibited in eligible recipient’s bedrooms and bathrooms. This service is not intended to provide for paid, in-person on-site response. On-site response must be planned through back up plans that are developed using natural or other paid supports. Assistive technology services are limited to five thousand dollars ($5,000) every five years.
C. Behavior support consultation: Behavior support consultation services consist
of functional support assessments, treatment plan development, and training and
support coordination for the eligible recipient related to behaviors that
compromise the eligible recipient’s quality of life.
D. Community supports coordinator:
Community support coordination services are intended to educate, guide
and assist the eligible recipient to make informed planning decisions about
services and supports, and monitor those services and supports. Specific waiver function(s) that CSC
providers have are:
(1) monitor
service delivery and conduct face-to-face visits including home visits at least
quarterly;
(2) complete
process to evaluate/re-evaluate level of care (medical eligibility);
(3) educate, train
and assist eligible recipient (and guardian, employer of record) about
participant direction or agency-based service delivery models (includes
adherence to standards, review of rights, recognizing and reporting critical
incidents);
(4) provide support and assistance during
the medical and financial eligibility process;
(5) develop the person-centered plan with
the eligible recipient; to include revising the plan as needed;
(6) serve as
an advocate for the eligible recipient to enhance their opportunity to be
successful with participant-direction or agency-based program; and
(7) supports the
recipient with identifying resources outside of the supports waiver that may
assist with meeting the recipient’s needs.
E. Customized community supports
individual: Customized community supports consist
of individualized services and support that enable an individual to acquire,
maintain, and improve opportunities for independence, community membership, and
inclusion. The provider may be a skilled
independent contractor or a hired employee depending on the level of support
needed by the eligible recipient to access the community. Customized community supports services are
designed around the preferences and choices of each individual and offers skill
training and supports to include: adaptive skill development, adult educational
supports, citizenship skills, communication, social skills, socially
appropriate behaviors, self-advocacy, informed choice, community inclusion,
arrangement of transportation, and relationship building. Customized community support services provide
help to the individual to schedule, organize and meet expectations related to
chosen community activities. All services are provided in a community setting
with the focus on community exploration and true community inclusion.
F. Customized community supports group: Customized community supports can include
participation in congregate community day programs and centers that offer functional
meaningful activities that assist with acquisition, retention, or improvement
in self-help, socialization and adaptive skills for an eligible recipient. Customized community supports may include
adult day habilitation, adult day health and other day support models. Customized community supports are provided in
community day program facilities and centers and can take place in
non-institutional and non-residential settings.
G. Employment
support:
Individual community integrated employment offers one-to-one support to
an eligible recipient placed in inclusive jobs or self-employment in the
community and support is provided at the worksite as needed for the eligible
recipient to learn and perform the tasks associated with the job in the workplace. The provider agency is encouraged to develop
natural supports in the workplace to decrease the reliance of paid supports.
H. Environmental
modifications: Services include the
purchase and installation of equipment or making physical adaptations to an eligible
recipient’s residence that are necessary to ensure the health, welfare and
safety of the eligible recipient or enhance the eligible recipient’s level of
independence.
(1) adaptations include: installation of ramps; widening of doorways
and hallways; installation of specialized electric and plumbing systems to
accommodate medical equipment and supplies; installation of lifts or elevators;
modification of bathroom facilities such as roll-in showers, sink, bathtub, and
toilet modifications, water faucet controls, floor urinals and bidet
adaptations and plumbing; turnaround space adaptations; specialized
accessibility and safety adaptations or additions; trapeze and mobility tracks
for home ceilings; automatic door openers or doorbells; voice-activated,
light-activated, motion-activated and electronic devices; fire safety
adaptations; air filtering devices; heating or cooling adaptations; glass
substitute for windows and doors; modified switches, outlets or environmental
controls for home devices; and alarm and alert systems or signaling devices;
(2) environmental
modifications are limited to five thousand dollars ($5000) every five years;
(3) all services
shall be provided in accordance with federal, state, and local building codes;
(4) excluded are
those adaptations or improvements to the home that are of general utility and
are not of direct medical or remedial benefit to the eligible recipient, such
as fences, storage sheds, or other outbuildings. Adaptations that add to the square footage of
the home are excluded for this benefit except when necessary to complete an
adaptation.
I. Personal care services: Personal
care services are provided on an intermittent basis to assist an eligible
recipient 21 years and older with a range of activities of daily living,
performance of incidental homemaker and chore service tasks if they do not
comprise of the entirety of the service, and enable the eligible recipient to
accomplish tasks he or she would normally do for themselves if they did not
have a disability. Personal care direct
support services are provided in the eligible recipient’s own home and in the
community, depending on the eligible recipient’s needs. The eligible recipient identifies the
personal care direct support worker’s training needs through the ISP in
addition to required training, and, if the eligible recipient or EOR for the
participant directed service delivery model or agency is unable to do the
training for themselves, the eligible recipient or EOR for the participant
directed service delivery model or agency arranges for the needed
training. Supports shall not replace
natural supports available such as the eligible recipient’s family, friends,
and individuals in the community, clubs, and organizations that are able and
consistently available to provide support and service to the eligible
recipient. Personal care services are
covered under the medicaid state plan as enhanced
early and periodic screening, diagnostic and treatment (EPSDT) benefits for
supports waiver eligible recipients under 21 years of
age and are not to be included in an eligible recipient’s AAB.
J. Non-medical transportation: Transportation
services are offered to enable eligible recipients to gain access to services,
activities, and resources, as specified by the ISP. Transportation services under the waiver are
offered in accordance with the eligible recipient’s ISP. Transportation services provided under the
waiver are non-medical in nature whereas transportation services provided under
the medicaid state plan are to transport eligible
recipients to medically necessary physical and behavioral health services. Payment for supports waiver transportation
services is made to the eligible recipient’s individual transportation provider
or employee or to a public or private transportation service vendor. Payment cannot be made
to the eligible recipient. Non-medical
transportation services for minors is not a covered service as these are
services that a legally responsible individual (LRI) would ordinarily provide
for household members of the same age who do not have a disability or chronic
illness. Payment cannot be made to the
eligible recipient. Whenever possible,
family, neighbors, friends, or community agencies that can provide this service
without charge shall be identified in the ISP and utilized.
K. Vehicle
modifications: Vehicle adaptations
or alterations to an automobile or van that is the eligible recipient’s primary
means of transportation in order to accommodate the special needs of the
eligible recipient. Vehicle adaptations
are specified by the service plan as necessary to enable the eligible recipient
to integrate more fully into the community and to ensure the health, welfare
and safety of the eligible recipient.
The vehicle that is adapted may be owned by the eligible recipient, a
family member with whom the eligible recipient lives or has consistent and
on-going contact, or a non-relative who provides primary long-term support to
the eligible recipient and is not a paid provider of services. Vehicle modifications are limited to five
thousand dollars ($5000) every five years.
Payment may not be made to adapt the vehicles that are owned or leased
by paid providers of waiver services.
Vehicle accessibility adaptations consist of installation, repair,
maintenance, training on use of the modifications and extended warranties for
the modifications. The following are
specifically excluded:
(1) adaptations
or improvements to the vehicle that are of general utility, and are not of
direct medical or remedial benefit to the eligible recipient;
(2) purchase or
lease of a vehicle; and
(3) regularly
scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of
the modifications.
L. Respite:
Respite is a family support service, the
primary purpose of which is to give the primary, unpaid caregiver time away
from their duties on a short-term basis.
Respite services include assisting the eligible recipient with routine
activities of daily living (e.g., bathing, toileting, preparing or assisting
with meal preparation and eating), enhancing self-help skills, and providing
opportunities for leisure, play and other recreational activities; assisting
the eligible recipient to enhance self-help skills, leisure time skills and
community and social awareness; providing opportunities for community and
neighborhood integration and involvement; and providing opportunities for the
eligible recipient to make their own choices with regard to daily
activities. Respite services are
furnished on a short-term basis and can be provided in the eligible recipient’s
home, the provider’s home, or in a community setting of the family’s choice
(e.g., community center, swimming pool and park).
[8.314.7.14 NMAC - N, 4/1/2021]
8.314.7.15 NON-COVERED
SERVICES: The waiver does not pay for the purchase of
goods or services that a household without a person with a disability would be
expected to pay for as a routine household or personal expense. If the eligible recipient requests a specific
good or service, the CSC and the state can work with the eligible recipient to find other, including less
costly, alternatives. Non-covered
services include, but are not limited to the following:
A. Services covered by the medicaid state plan (including EPSDT), MAD school-based
services, medicare and other third parties.
B. Any
service or good,
the provision of which would violate federal
or state statutes, regulations or
guidance.
C. Formal academic degrees or
certification-seeking education, educational services covered by IDEA or vocational training provided by
the public education department (PED), division of vocational rehabilitation
(DVR.
D. Food and shelter expenses, including
property-related costs, such as rental or purchase of real estate and
furnishing, maintenance, utilities and utility deposits, and related
administrative expenses; utilities include
gas, electricity, propane, firewood, wood pellets, water, sewer, and waste
management.
E. Experimental or investigational
services, procedures or goods, as defined in 8.325.6 NMAC.
F. Any goods or services that are to be
used for recreational or diversional purposes.
G. Personal goods or items not related
to the disability.
H. Animals and costs of maintaining animals
including the purchase
of food, veterinary visits, grooming and boarding except for training and
certification for service dogs.
I. Gas cards and gift cards.
J. Purchase of insurance, such as car,
health, life, burial, renters, homeowners, service warranties or other such policies.
K. Purchase of a vehicle, and long-term
lease or rental of a vehicle.
L. Purchase of recreational vehicles,
such as motorcycles, campers, boats or other similar items.
M. Firearms, ammunition or other
weapons.
N. Vacation expenses, including airline
tickets, cruise ship or other means of transport, guided.
O. Meals, hotel, lodging or similar
recreational expenses.
P. Purchase of usual and customary
furniture and home furnishings, unless adapted
to the eligible recipient’s disability or use, or of specialized benefit to the
eligible recipient’s condition; requests for adapted or specialized furniture or furnishings must include a
recommendation from the eligible recipient’s health care provider and, when
appropriate, a denial of payment from any other source.
Q. Regularly scheduled upkeep, maintenance and repairs of a
home and addition of fences, storage sheds or other outbuildings, except upkeep and maintenance of modifications or alterations to a home which are an
accommodation directly related to the eligible recipient’s qualifying condition
or disability.
R. Regularly scheduled upkeep,
maintenance and repairs
of a vehicle, or tire purchase or replacement,
except upkeep and maintenance of
modifications or alterations to a vehicle or van, which is an accommodation
directly related to the eligible
recipient’s qualifying condition or disability; requests
must include documentation
that the adapted vehicle is the eligible
recipient’s primary means of transportation.
S. Clothing and accessories, except specialized clothing
based on the eligible recipient’s disability
or condition.
T. Training expenses for paid employees.
U. Costs associated with such conferences or class cannot be
covered, including airfare, lodging or meals;
consumer electronics such as computers, printers and fax machines, or other electronic equipment that does not meet the criteria specified in
Subsection A of 8.314.6.14 NMAC; no more than one of each type of item may be
purchased at one time; and consumer electronics may not be replaced more
frequently than once every three years.
V. Cell phone services
that include fees for data unless data is for an app
specifically approved through supports waiver funds; or more than one cell phone line per eligible recipient.
[8.314.7.15
NMAC - N, 4/1/2021]
8.314.7.16 INDIVIDUAL SERVICE PLAN (ISP) AND AUTHORIZED
ANNUAL BUDGET(AAB): An ISP and an AAB request are developed at
least annually by the eligible recipient in collaboration with the eligible
recipient’s CSC and others that the eligible recipient invites to be part of
the process. The CSC serves in a
supporting role to the eligible recipient, assisting the eligible recipient to
understand the supports waiver program, and with developing and implementing
the ISP and the AAB. The ISP and annual
budget request are developed and implemented as specified in 8.314.7. NMAC and supports waiver service standards
and submitted to the TPA or MAD’s designee for final approval. Upon final approval the annual budget request
becomes an AAB.
A. ISP development process: For
development of the person-centered service plan, the planning meetings are
scheduled at times and locations convenient to the eligible recipient. This process obtains information about
eligible recipient strengths, capacities, preferences, desired outcomes and
risk factors through the LOC assessment process and the planning process that
is undertaken between the CSC and eligible recipient to develop their ISP.
(1) Assessments:
(a) assessment activities that
occur prior to the ISP meeting assist in the development of an accurate and
functional plan. The functional
assessments conducted during the LOC determination process address the
following needs of a person: medical, behavioral health, adaptive behavior
skills, nutritional, functional, community/social and employment;
(b) assessments
occur on an annual basis or during significant changes in circumstance or at
the time of the LOC determination. After
the assessments are completed, the results are made available to the eligible
recipient and their CSC for use in planning;
(c) the eligible
recipient and the CSC will assure that the ISP addresses the information and
concerns, if any, identified through the assessment process.
(2) Pre-planning:
(a) the
CSC contacts the eligible recipient upon their choosing enrollment in the
supports waiver program to provide information regarding this program,
including the range and scope of choices and options, as well as the rights,
risks, and responsibilities associated with participation in the supports
waiver;
(b) the CSC discusses
areas of need to address on the eligible recipient’s ISP. The CSC provides support during the annual
re-determination process to assist with completing medical and financial
eligibility in a timely manner;
(3) ISP components: The ISP contains:
(a) the supports waiver
services that are furnished to the eligible recipient, the projected amount,
frequency and duration, and the type of provider who furnishes each service;
(i) the ISP must
describe in detail how the services or goods relate to the eligible recipient’s
qualifying condition or disability;
(ii) the ISP must
describe how the services and goods support the eligible recipient to remain in
the community and reduce their risk of institutionalization; and
(iii) the ISP must specify
the hours of services to be provided and payment arrangements.
(b) other services needed by the
supports waiver eligible recipient regardless of funding source, including
state plan services;
(c) informal supports that
complement supports waiver services in meeting the needs of the eligible
recipient;
(d) methods
for coordination with the medicaid state plan
services and other public programs;
(e) methods
for addressing the eligible recipient’s health care needs when relevant;
(f) quality
assurance criteria to be used to determine if the services and goods meet the
eligible recipient’s needs as related to their qualifying condition or
disability;
(g) information,
resources or training needed by the eligible recipient and service providers;
(h) methods
to address the eligible recipient’s health and safety, such as emergency and
back-up services.
(4) Individual service plan meeting:
(a) the eligible recipient receives a LOC assessment
and local resource manual and person-centered planning documents prior to the
ISP meeting;
(b) the eligible
recipient may begin planning and drafting the ISP utilizing those tools prior
to the ISP meeting;
(c) during the ISP meeting, CSC assists the eligible recipient to ensure that the ISP addresses the eligible recipient’s goals, health, safety and risks. The eligible recipient and their CSC will assure that the ISP addresses the information, goals and concerns identified in the person-centered planning process. The ISP must address the eligible recipient’s health and safety needs before addressing other issues. The CSC ensures that:
(i) the planning process addresses the eligible recipient’s needs and goals in the following areas: health and wellness and accommodations or supports needed at home and in the community;
(ii) services selected address
the eligible recipient’s needs as identified during the assessment process;
needs not addressed in the ISP will be addressed outside the supports waiver
program;
(iii) the outcome of the
assessment process for assuring health and safety is considered in the plan;
(iv) services
do not duplicate or replace those available to the eligible recipient through
the medicaid state plan or other programs;
(v) services
are not duplicated in more than one service code;
(vi) job
descriptions are complete for each provider and employee in the plan; a job
description will include frequency, intensity and expected outcomes for the
service;
(vii) the quality
assurance section of the ISP is complete and specifies the roles of the
eligible recipient, community supports coordinator and any others listed in
this section;
(viii) the
responsibilities are assigned for implementing the plan;
(ix) the
emergency and back-up plans are complete; and
(x) the ISP
is submitted to the TPA after the ISP meeting, in compliance with supports
waiver rules and service standards.
B. ISP review criteria: Services
and related goods identified in the eligible recipient’s requested ISP may be
considered for approval if the following requirements are met:
(1) the
services or goods must be responsive to the eligible recipient’s qualifying
condition or disability and must address the eligible recipient’s clinical,
functional, medical or habilitative needs; and
(2) the
services or goods must accommodate the eligible recipient in managing their
household; or
(3) the
services or goods must facilitate activities of daily living;
(4) the
services or goods must promote the eligible recipient’s personal health and
safety; and
(5) the
services or goods must afford the eligible recipient an accommodation for
greater independence; and
(6) the
services or goods must support the eligible recipient to remain in the
community and reduce his/her risk for institutionalization; and
(7) the
services or goods must be documented in the ISP and advance the desired
outcomes in the eligible recipient’s ISP; and
(8) the ISP contains the quality
assurance criteria to be used to determine if the service or goods meet the
eligible recipient’s need as related to the qualifying condition or disability;
and
(9) the
services or goods must decrease the need for other MAD services; and
(10) the
eligible recipient receiving the services or goods does not have the funds to
purchase the services or goods; or
(11) the
services or goods are not available through another source; the eligible
recipient must submit documentation that the services or goods are not
available through another source, such as the medicaid
state plan or medicare; and
(12) the
service or good is not prohibited by federal regulations, NMAC rules, billing
instructions, standards, and manuals; and
(13) each
service or good must be listed as an individual line item whenever possible;
however, when a service or a good are ‘bundled’ the ISP must document why bundling
is necessary and appropriate.
C. Budget review criteria: The
eligible recipient’s proposed annual budget request may be considered for
approval, if all the following requirements are met:
(1) the
proposed annual budget request is within the supports waiver IBA;
(2) the rate
for each service is included;
(3) the proposed cost for each good
is reasonable, appropriate and reflects the lowest available cost for that
chosen good;
(4) the
estimated cost of the service or good is specifically documented in the
eligible recipient’s budget worksheets; and
(5) no
employee exceeds 40 hours paid work in a consecutive seven-day work week.
D. Modification of the ISP:
(1) The ISP may be modified based
upon a change in the eligible recipient’s needs or circumstances, such as a
change in the eligible recipient’s health status or condition or a change in
the eligible recipient’s support system, such as the death or disabling
condition of a family member or other individual who was providing services.
(2) If
the modification is to provide new or additional services than originally
included in the ISP, these services must not be able to be acquired through
other programs or sources. The eligible
recipient must document the fact that the services are not available through
another source. The new or additional
services are subject to utilization review for medical necessity and program
requirements as per 8.314.7.17 NMAC.
(3) The CSC initiates the process to
modify the ISP by forwarding the request for modification to the TPA for
review.
(4) The ISP must be modified before there
is any change in the AAB.
(5) The ISP may be modified once the
original ISP has been submitted and approved.
Only one ISP revision may be submitted at a time, e.g.; an ISP revision
may not be submitted if an initial ISP request or prior ISP revision request is
under initial review by the TPA. This
requirement also applies to any re-consideration of the same revision
request. Other than for critical health
and safety reasons, neither the ISP nor the AAB may be modified within 60
calendar days of the expiration of the current ISP.
[8.314.7.16 NMAC - N, 4/1/2021]
8.314.7.17 PRIOR AUTHORIZATION AND UTILIZATION REVIEW: All
MAD services, including services covered under the supports waiver program, are
subject to utilization review for medical necessity and program
requirements. Reviews by MAD or its
designees may be performed before services are furnished, after services are
furnished, before payment is made, or after payment is made in accordance with
8.310.2 NMAC.
A. Prior authorization: Services,
supports, and goods specified in the ISP and AAB require prior authorization
from HSD/MAD or its designee. The ISP
must specify the type, amount and duration of services. Services for which prior authorization was
obtained remain subject to utilization review at any point in the payment
process.
B. Eligibility determination: To
be eligible for supports waiver program services, eligible recipients must require
the LOC of services provided in an ICF-IID.
Prior authorization of services does not guarantee that applicants or
eligible recipients are eligible for medical assistance program (MAP) or
supports waiver services.
C. Reconsideration: If
there is a disagreement with a prior authorization denial or other review
decision, the community supports coordinator provider on behalf of the eligible
recipient, can request reconsideration from the TPA that performed the initial
review and issued the initial decision.
Reconsideration must be requested within 30-calendar days of the date on
the denial notice, must be in writing and provide additional documentation or
clarifying information regarding the eligible recipient’s request for the
denied services or goods.
D. Denial of payment: If
a service, support, or good is not covered under the supports waiver program,
the claim for payment may be denied by MAD or its designee. If it is determined that a service is not
covered before the claim is paid, the claim is denied. If this determination is
made after payment, the payment amount is subject to recoupment or repayment.
[8.314.7.17 NMAC - N, 4/1/2021]
8.314.7.18 RECORDKEEPING
AND DOCUMENTATION RESPONSIBILITIES: Service providers and vendors who furnish
goods and services to supports waiver eligible recipients are reimbursed by the
financial management agency (FMA) and must comply with all applicable New
Mexico administrative code (NMAC), medical assistance division (MAD) rules and
service standards. The FMA, community
supports coordinators (CSC) and service providers must maintain records, which
are sufficient to fully disclose the extent and nature of the goods and
services provided to the eligible recipients, as detailed in applicable NMAC,
MAD provider rules and comply with random and targeted audits conducted by MAD
and department of health (DOH) or their audit agents. MAD or its designee will seek recoupment of
funds from service providers when audits show inappropriate billing for
services. Supports waiver vendors who
furnish goods and services to supports waiver eligible recipients and bill the
FMA must comply with all MAD provider participation agreement (PPA)
requirements and NMAC, MAD rules and requirements, including but not limited to
8.310.2 NMAC and 8.321.2 NMAC and 8.302.1 NMAC.
[8.314.7.18 NMAC - N, 4/1/2021]
8.314.7.19 REIMBURSEMENT: Health
care to MAP eligible recipients is furnished by a variety of providers and
provider groups. The reimbursement and billing
for these services is administered by MAD.
A. Agency-based service delivery
model provider reimbursement: Upon approval of a New
Mexico MAD provider participation agreement (PPA) by MAD or its designee,
licensed practitioners, facilities, and other providers of services that meet
applicable requirements are eligible to be reimbursed for furnishing covered
services to MAP eligible recipients. A
provider must be enrolled before submitting a claim for payment to the MAD
claims processing contractors. MAD makes
available on the human service department/medical assistance division (HSD/MAD)
website, on other program-specific websites, or in hard copy format,
information necessary to participate in health care programs administered by
HSD or its authorized agents, including New Mexico administrative code (NMAC)
rules, billing instructions, utilization review instructions, service
definitions and service standards and other pertinent materials. When enrolled, a provider receives instruction on how to access these
documents. It is the provider’s
responsibility to access these instructions, to understand the information
provided and to comply with the requirements.
The provider must contact HSD or its authorized agents to obtain answers
to questions related to the material or not covered by the material. To be eligible for reimbursement, a provider
must adhere to the provisions of the MAD PPA and all applicable statutes,
regulations, and executive orders. MAD or its selected claims processing
contractor issues payments to a provider using electronic funds transfer (EFT)
only.
B. Participant directed service delivery model provider and vendor reimbursement: Supports
waiver eligible recipients must follow all billing instructions provided
by the FMA to ensure payment of service providers, employees, and vendors. Claims must be billed to the FMA per the
billing instructions. Reimbursement to a
service provider and a vendor in the supports waiver program is made, as
follows:
(1) supports
waiver service provider and vendor must enroll with the FMA;
(2) the eligible recipient receives instructions and
documentation forms necessary for a service provider’s and a vendor’s claims
processing;
(3) an eligible recipient must submit claims for
payment of their supports waiver service provider and vendor to the FMA for
processing; claims must be filed per the billing instructions provided by the
FMA;
(4) the eligible
recipient and their supports waiver service provider and vendor must follow all
FMA billing instructions; and
(5) reimbursement
of a supports waiver service provider and vendor is made at a predetermined
reimbursement rate by the eligible recipient with the supports waiver service
provider or vendor, approved by the TPA contractor, and documented in the ISP
and in the supports waiver provider or vendor agreement; at no time can the
total expenditure for services exceed the eligible recipient’s AAB;
(6) the FMA must submit claims that have been paid by the
FMA on behalf of the eligible recipient to the MAD fiscal contractor for
processing; and
(7) reimbursement
may not be made directly to the eligible recipient, either to reimburse them
for expenses incurred or to enable the eligible recipient to pay a service
provider directly.
[8.314.7.19 NMAC - N, 4/1/2021]
8.314.7.20 RIGHT
TO AN HSD ADMINISTRATIVE HEARING:
A. The human services
department/medical assistance division (HSD/MAD) must grant an opportunity for
an administrative hearing as described in this section in the following circumstances and pursuant to 42 CFR Section 431.220(a)(1), Section 27-3-3 NMSA 1978 and 8.352.2 NMAC Recipient Hearings:
(1) when a
supports waiver applicant has been determined not to meet the LOC requirement
for waiver services;
(2) when a
supports waiver applicant has not been given the choice of HCBS as alternative
to institutional care;
(3) when a
supports waiver applicant is denied the services of their choice or the
provider of their choice;
(4) when a
supports waiver recipient’s services are denied, suspended, reduced or
terminated;
(5) when a
supports waiver recipient has been involuntarily terminated from the program;
or
(6) when a
supports waiver recipient’s request for a budget adjustment has been denied.
B. DOH and its counsel, if necessary,
shall participate in any fair hearing involving an eligible recipient. HSD/MAD, and its counsel, if necessary, may
participate in fair hearings.
[8.314.7.20 NMAC - N, 4/1/2021]
8.314.7.21 CONTINUATION
OF BENEFITS PURSUANT TO TIMELY APPEAL:
A. Continuation of benefits
may be provided to eligible
recipients who request
an HSD administrative hearing within
the timeframe defined in 8.352.2 NMAC.
The notice will include information on the right to continued benefits and
on the eligible recipient’s responsibility for repayment if the hearing
decision is not in the eligible recipient’s favor. See 8.352.2 New Mexico administrative code
(NMAC) for a complete description of the continuation of benefits process of an
HSD administrative hearing for an eligible recipient.
B. The continuation of benefit is only available to an
eligible recipient that is currently receiving the appealed benefit. The eligible recipient’s current
AAB and ISP at the
time of the request is termed a ‘continuation’ of
benefits. The continuation budget may
not be revised until the conclusion
of the fair hearing process.
[8.314.7.21 NMAC - N, 4/1/2021]
8.314.7.22 GRIEVANCE/COMPLAINT
SYSTEM: An eligible recipient has the opportunity to register grievances or complaints concerning the provision of
services under the supports waiver program.
Eligible recipients may register complaints with either HSD/MAD or
DOH/DDSD via e-mail, mail or phone.
Complaints will be referred to the appropriate department for
resolution. The eligible recipient is
informed that filing a grievance or complaint is not a prerequisite or
substitute for a fair hearing.
[8.314.7.21 NMAC - N, 4/1/2021]
HISTORY OF 8.314.7 NMAC: [RESERVED]